A male neonate 21 days old who is breast fed, with positive moro reflex, with good weight gain and yellow colored stool.
On day 9: TSB 9.2mg/dl, PCV =50
On day 11: TSB 8.6mg/dl; Direct bilirubin 2.5mg/dl; PCV 50
On day 14: TSB 8.2; Direct bilirubin 2.2mg/dl; PCV 50
On day 21: TSB 6.5mg/dl; direct bilirubin 2.5mg/dl; PCV 43
Non fasting Ultrasound: normal size and texture for kidneys, spleen, liver, gallbladder and common bile duct, with no stones
Day 22: Stop breastfeeding and start formula milk for 48 hours
Day 25: TSB 7.6mg/dl; Direct bilirubin 2.4mg/dl; PCV 41
So what is the expected diagnosis for this case?
This scenario cannot be considered as neonatal cholestasis.
Neonatal cholestasis is defined biochemically as prolonged elevation of the serum levels of conjugated bilirubin beyond the first 14 days of life.
It can be divided into extrahepatic and intrhepatic disease.
One should expect a higher increase in unconjugated bilirubin in such patient, but this is not the case, evidently. Total biulirubin is quite normal for such an age, but conjugated bilirubin is rather elevated. I should ask for previous values of total and conjugated bilrubin to view all the curve since birth to give a more accurate answer.
How do other liver function tests behave? A similar level of CB with a total bilirubin around 9 can also result from a "false positive" direct reaction of UCB. Please keep us updated.
The child has colored stools so I guess it has no sign of biliary atresia. Check if there is not a deficit alpha-1-antitrypsine.
El aumento de la fracción conjugada de la bilirrubina en un recién nacido de 11 días debe considerarse patológica. Puede ser infección bacteriana sobre todo urinaria, viral o parasitaria (agentes del TORCH sobre todo CMV), atresia de la vía biliar, deficiencia de alfa 1 antitripsina o EIM como tirosinemia , galactosemia etc....
Es importante saber si la colestasis se acompaña de alteración de la función hepática.
First of all, I would like to thank all researchers about their answers.
This child is now 14 days and the TSB = 8.3mg/dl , and Direct Bilirubin = 2.2 mg/dl.
But unfortunately testing for bilirubin at earlier times was not done
in this case as CB is a bit high i would ask for liver enzymes(SGPT){ if abn then do viral marker} and the stool color, and abdominal US, if still in doubt then go for HIDA scan, although with normal stool color and a visible GB in US safly i can wait and observe.
In this case,direct bilirubin is slightly higher. I would like to ask that, is there any other abnormal physical or laboratory abnormality (e.g. AST, ALT, ALP, GGT)? Is his parents are relative? or is there any family history?. I think the patient sould be closely followed up for direct bilirubin trend. If it continues to rise, then detailed eveluation should be done (such as for sepsis, TORCH-S group infections, metabolic causes (e.g. galactosemia),congenital hypothyroidism, alpha-1-antitrypsine deficiency, biliary atresia,PFIC, cystic fibrosis, syndromic causes (e.g. Alagille syndrome, Dubin-Johnson syndrome, Rotor syndrome).
Dear Mustafa thank you for your answer.
Actually there is no any lab test done other than PCV which is normal and bilirubin was done, the parents are not relative and no family history
I think the patient should be closely followed up if direct bilirubin continues to rise. If it continues to rise, then please order pediatric gastroenterology consultation for doing detailed evaluation and giving ursodeoxycholic acid and vitamin ADEK.
I recommend close follow-up Whether congugated bilirubin continues to rise, if it is yes, then give ursodeoxycholic acid and vitamin ADEK, and consult with a pediatric gastroenterologist to identifing the underlying cause.
The above answers are correct, but a direct answer to your question...by definition, direct bilirubin >1.0 and/or >20% total serum bilirubin (TSB) IS already cholestatic jaundice with etiology/underlying cause to be determined.
If direct Bi is 2mg/dl or 20% from TSB,it is cholestasys! I would investigate this baby by abdominal US,because it could be some congenital hepato-billiar system surgical problem and start use Ursofalk
However you approach the diagnosis the clock may already be ticking. You have only about 30 days before a possible surgical correction will prevent irreversible liver damage.
I think he need some additional lab tests such as alphafetoprotein and gamma glutamil transpeptidase for differential diagnosis and a HIDA scan after 5 days use of phenobarbital.
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